Consent Form for Observation of Service over Teleconferencing
I understand that my Clinician _______________________, has requested assistance from _______________________ at SC Department of Mental Health via a long distance interactive video link.
I understand that my clinician will be providing mental health services in the usual fashion with the clinician from SC Department of Mental Health (DMH) observing at a distance. I understand that it may be necessary for professional support personnel to be present at both ends of the video link to help with the transmission. In addition, I understand that clinicians in training working with the SC Department of Mental Health physician may be present.
I hereby authorize my physician to communicate to the clinicians, doctors in training and support personnel at DMH any and all information about my health, including prior health history, present complaints and laboratory and diagnostic data which my clinician feels necessary to be communicated to enable those providers at DMH to assist my clinician in this service. I also hereby authorize the providers at DMH to access any records in my DMH chart which they may deem necessary to assist them in providing consultation services to my clinician in this video link consultation.
I have been advised that the health care providers at SC Department of Mental Health will respect my privacy and confidentiality in the same fashion as any face to face or telephone interaction between a patient and health care providers.
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Patient's Signature
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Witness